[Tinea capitis. Therapeutic options in the post-griseofulvin era]

The significance of itraconazole for treatment of fungal infections of skin, nails and mucous membranes

Itraconazole is an antifungal drug from the triazole group with distinct in vitro activity against dermatophytes, yeasts and some molds. Itraconazole has a primarily fungistatic activity. Itraconazole accumulates in the stratum corneum and in nail material due to its high affinity to keratin, as well as in sebum and vaginal mucosa. Together with terbinafine and fluconazole, itraconazole belongs to the modern highly effective systemic antifungal drugs with a favorable risk-benefit ratio and for this reason is a preferred therapy option for fungal infections of skin, nails and mucous membranes. Compared to terbinafine in the treatment of fingernail and toenail fungal infections, itraconazole offers the advantage of a broad antifungal spectrum and better effectiveness against onychomycosis caused by yeasts yet appears inferior with regard to the more common dermatophyte infections. Itraconazole constitutes an important therapy option, along with fluconazole, terbinafine, ketoconazole and griseofulvin, for the treatment of dermatophyte infections of glabrous skin (tinea pedis, tinea manuum, tinea corporis and tinea cruris) in adults following unsuccessful topical therapy. In the oral therapy of tinea capitis, itraconazole plays an especially important role, in particular for disease caused by Microsporum canis (for children, however, only off-label use is feasible currently). In the treatment of oropharyngeal candidiasis, candidiasis of the skin and vulvovaginal candidiasis, itraconazole and fluconazole are the preferred treatment options in cases in which topical therapy has proven unsuccessful.

Pediatric tinea capitis: recognition and management

Tinea capitis (ringworm of the head) is the most common dermatophytosis of childhood with an increasing incidence worldwide. If suspected clinically, further diagnostic procedures, including direct microscopy and culture, should be performed. Other scalp alterations, such as seborrheic dermatitis, atopic eczema, psoriasis, alopecia areata, folliculitis, and pseudopelade, may mimic ringworm of the head and must be identified. A proven fungal infection of scalp skin and hairs warrants immediate initiation of systemic treatment. At present, only oral griseofulvin is approved for therapy of scalp ringworm in children by health authorities. However, the advent of several newer antifungal agents such as itraconazole, fluconazole, and terbinafine has broadened the therapeutic armamentarium in recent years. These agents offer shorter treatment intervals, and their adverse effects and drug interaction profiles appear to be well within acceptable limits. In patients with tinea capitis, systemic therapy at weight-dependent dosages for an appropriate amount of time in conjunction with topical supportive measures will help to prevent disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions, and infection of other persons.

[New and established methods in therapy of hair diseases]

Recently rational drug therapy and potent technologies have been introduced for the treatment of the most frequent hair problems, i.e. finasteride in the treatment of male pattern hair loss, and laser-assisted hair removal systems for hypertrichosis and hirsutism. Together with the availability of such treatments, high technical standards for evaluating their efficacy have been developed, e.g. computer-assisted epiluminiscence microscopy. Besides these physical aspects, life quality has also become an important issue in clinical studies, and is assessed by standardized patient questionnaires. In the treatment of hair loss, women have become reluctant about taking systemic hormones since the results of large epidemiological studies on the risks of hormonal replacement therapy have become public. Topical 17alpha-estradiol offers an alternative, though its efficacy has not been proven. The results of double-blinded, placebo-controlled studies demonstrating efficacy are yet only available for topical minoxidil. In the treatment of alopecia areata, there is no treatment that guarantees regrowth and stable growth of recovered hair. Only topical immunotherapy produces a higher remission rate that the natural evolution of disease. Scarring alopecias are not frequent but they need a careful evaluation, including scalp biopsy, for a precise diagnosis, because of irreversibility and potentially grave cosmetic consequences. The introduction of the modern broad spectrum antimycotic agents has greatly improved the management of infectious scarring alopecias. Finally, developments in hair care and anti-aging medicine are discussed, with special referral to the evolving difficulty of delineating medical science from marketing strategies in this trendy field.